Provider Demographics
NPI:1679508162
Name:NORTHERN CALIFORNIA RETIRED OFFICERS COMMUNITY
Entity Type:Organization
Organization Name:NORTHERN CALIFORNIA RETIRED OFFICERS COMMUNITY
Other - Org Name:LAUREL CREEK HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:F
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-432-1100
Mailing Address - Street 1:2600 ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-9711
Mailing Address - Country:US
Mailing Address - Phone:707-432-1100
Mailing Address - Fax:
Practice Address - Street 1:2800 ESTATES DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-9712
Practice Address - Country:US
Practice Address - Phone:707-432-1200
Practice Address - Fax:707-426-1130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000338314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
555727Medicare PIN